Tracheal stenosis after placement of percutaneous dilational tracheotomy

Objectives: Percutaneous dilational tracheotomy procedures have been used successfully as a bedside alternative to open surgical tracheotomy. At our institution, we have seen patients with tracheal injuries following this procedure. In this paper, we review those cases to demonstrate that tracheal stenosis is a potential long‐term complication of percutaneous dilational tracheotomy. Study Design: Case series. Methods: Patients were evaluated with computed tomography and operative endoscopy. Inpatient and outpatient records were reviewed retrospectively. Results: Nine patients were referred to our practice for management of tracheal stenosis after percutaneous dilational tracheotomy between 2003 and 2006. Presence of anterior tracheal ring compression and destruction or lateral wall collapse was noted in each case. Endoscopy revealed stenosis secondary to anterior tracheal wall injury in all cases. In eight of nine cases, operative intervention was needed to correct the stenotic segment. Conclusions: It has been demonstrated in the literature that with 20 years of experience, the percutaneous dilational tracheotomy procedure is more affordable, faster to perform, and a generally safe procedure when performed under appropriate conditions. Most case series of percutaneous dilational tracheotomy reveal an equal or lower risk of short‐term complications than open tracheotomy. This series demonstrates that tracheal stenosis is a potential long‐term complication. Longitudinal follow‐up of patients undergoing percutaneous dilational tracheotomy is indicated.     

气管插管导致气管狭窄的外科治疗

目的分析气管插管导致气管狭窄的临床特征,探讨其治疗方法。方法回顾性分析7例气管插管导致气管狭窄的临床资料,并介绍其治疗方法和疗效。结果实施狭窄气管袖状切除+端端吻合术的7例患者中6例均于术后5个月内拔管,随访3～24个月,未并发喉部狭窄及喉返神经损伤;1例患者因缺血缺氧性脑病死亡。结论气管插管是目前导致气管狭窄最常见的病因之一,正确的手术方法是治愈气管狭窄的重要手段。     

560例气管切开行机械通气患者并发气管狭窄的危险因素分析

目的探讨气管切开并行机械通气患者发生气管狭窄的危险因素。方法选择中山大学附属第一医院1990年1月—2006年6月气管切开并行机械通气治疗的560例患者为研究对象，就性别、年龄、术前有否气管插管、术前插管时间、术后持续机械通气时间、既往气管切开史、更换气管套管次数、环甲膜切开、呼吸道感染、糖尿病、胃食管反流等临床因素，用逐步Logistic回归进行多因素分析。结果本组560例中出现气管狭窄54例（9．6％），多因素分析结果：术前插管时间（χ^2=4.323，P=0．038）、术后持续机械通气时间（χ^2=14．062，P=0．000）、呼吸道感染（χ^2=8．604，P=0．004），糖尿病（χ^2=5．237，P=0．014）与气管狭窄发生有关。上述危险因素，按其影响的大小顺序为：机械通气时间（OR=10．818）、呼吸道感染（OR=6．349）、糖尿病（OR=3．019）、术前插管时间（OR=2．156）。结论气管切开并行机械通气患者并发气管狭窄的影响因素是多方面的。统计学研究表明，术前插管时间、术后机械通气持续时间、呼吸道感染和合并有糖尿病等是其危险因素。     

Polyflex stenting of tracheomalacia after surgery for congenital tracheal stenosis

Polyflex self-expanding stents (Rüsch, Germany) were used in three young children who had presented with life-threatening long-segment tracheal stenosis with bronchial stenosis in two cases. Two children had slide tracheoplasties and subsequently aortic homografts and another tracheal resection and autotracheoplasty. However, in all cases persistent lower tracheal malacia necessitated stenting. Complications of granuloma, stent migration or dislodgement occurred in all cases. A fatal tracheo-aortic fistula occurred in one child. Granuloma in one was treated successfully with steroids. One child survives.     

Prevention of laryngotracheal stenosis with carnitine after tracheotomy: an experimental study on rats

OBJECTIVE: We investigated the effect of carnitine on wound healing of trachea in tracheotomyzed rats. This study was undertaken to test the hypothesis that treatment with carnitine would protect the wound tissue, which was evaluated by measuring nitrite and nitrate, thus nitric oxide, malondialdehyde and cholinesterase in blood, and examining the histopathological changes. METHODS: Standard vertical tracheotomy was performed on 24 Wistar-Albino type rats. Then the animals were randomly divided into two groups; group A (the study group) was administered intraperitoneal carnitine 100 mg/kg for 10 days; group B (the control group) was administered intraperitoneal saline for 10 days. On the 10th day, all animals were decanulated. Three weeks later, cardiac blood samples were taken for biochemical assays and trachea specimens were harvested for histopathologic examination. RESULTS: In the carnitine-administered group, granulation tissue thickness resulting from the wound healing in the level of tracheotomy incision was lower compared to the control group (P < 0.01). When serum malondialdehyde levels were considered, a lower malondialdehyde level was found in the carnitine-administered group (P < 0.01). However, serum nitric oxide levels were close to each other in both groups (P > 0.05), while serum cholinesterase level was higher in the carnitine-administered group than in the control group (P < 0.01). CONCLUSION: Carnitine treatment partially prevents and significantly reduces the severity of tracheotomy induced laryngotracheal stenosis.     

Is T-tube treatment effective in Meyer-Cotton grade 3 tracheal stenosis: long-term outcomes

Objectives: To present retrospective experience in Meyer-Cotton grade 3 tracheal stenosis of 17 patients treated by T-tube, considering the characteristics of the treated stenosis, surgical procedures performed, and post-operative outcomes and complications.

Methods: All demographic and clinical data were collected retrospectively. Chest and neck computed tomography scans were performed to assess the stenosis, including length, location, and glottic involvement. The stenotic area was evaluated endoscopically according to an adapted Meyer and Cotton grading scale.

Results: The aetiology of the tracheal stenosis was intubation-related in all cases. The duration of intubation ranged between 1?hour to 40 days. According to the Myers-Cotton classification, all patients were at stage 3. Mean length of the stenosis was 26.58?±?12.02 (range =15–70) mm. Mean follow-up for the study group was 60.16?±?34.10 (range =18–137) months. Two patients died during follow-up, one due to stroke, one due to chronic lymphocytic leukemia; no deaths were attributable to TS. The remaining 15 patients could be evaluated up to the present time. Post-operative decannulation was achieved in three of 15 patients (20%), and decannulation was not achieved in 12 of 15 patients (80%).

Conclusion: T-tube is not an effective treatment of tracheal stenosis.     

CO2 laser treatment of tracheal stenosis

Conclusion: Delivery of a carbon dioxide laser is an effective method and can be used in selected cases of tracheal stenosis. Objectives: To present retrospective experience in tracheal stenosis of 16 patients treated by bronchoscopic delivery of carbon dioxide laser, considering the characteristics of the treated stenosis, surgical procedures performed, and post-operative outcomes and complications. Methods: All demographic and clinical data were collected retrospectively. Chest and neck computed tomography scans were performed to assess the stenosis, including length, location, and glottic involvement. The stenotic area was evaluated endoscopically according to an adapted Meyer and Cotton grading scale. Results: The aetiology of the tracheal stenosis was intubation-related in 14 cases, and idiopathic in two cases. The duration of intubation ranged between 1 hour to 26 days. According to the Myers-Cotton classification, mean stage of stenosis for the study group was 3.3 ± 0.5. Mean length of the stenosis was 23.75 ± 6.95 (range = 15–40) mm. Mean follow-up for the study group was 23.81 ± 7.11 (range = 12–38) months. Postoperative decannulation was achieved in 13 patients (81.3%), and decannulation was not achieved in three patients (18.7%).     

吡非尼酮抑制大鼠气管瘢痕狭窄和成纤维细胞功能的实验研究

目的探讨吡非尼酮（PFD）对大鼠气管瘢痕狭窄及成纤维细胞功能的影响。方法将20只SD 雄性大鼠通过气管切开和气管损伤手术构建气管狭窄模型，随机分成2组，实验组（10只）予以PFD胶囊粉末经口灌喂，50 mg/只/d；对照组（10只）予以无菌水经口灌喂，5 mL/只/d，两组连续灌喂10 d。手术14 d后HE染色检测气管瘢痕厚度，免疫组织化学检测TGFβ1、Collagen I和α SMA的表达情况。使用不同浓度的PFD处理RFL 6细胞，CCK 8法检测细胞存活率，划痕和Transwell实验检测细胞侵袭转移能力，Western blot法检测蛋白表达水平。结果HE染色显示PFD实验组大鼠气管瘢痕厚度为(337.5±33.5)μm，明显低于对照组瘢痕厚度(537.0±38.8)μm（P<0.001）；免疫组织化学结果显示TGFβ1、Collagen I和α SMA在实验组的表达强度明显低于对照组，两组比较差异均具有统计学意义（P<0.001）。细胞实验结果显示PFD能抑制RFL 6细胞的生长，浓度为1.5mM时效果明显（P<0.001）；PFD能减弱细胞的划痕愈合以及穿出Transwell小室的能力，与对照组比较差异均具有统计学意义（P<0.05）。Western blot检测显示PFD能明显下调RFL 6细胞中TGFβ1、Collagen I和α SMA的表达（P<0.001）。结论PFD能显著拮抗大鼠气管瘢痕形成，并能抑制成纤维细胞的增殖和转化、迁移愈合能力以及细胞外基质的分泌能力。     

金属支架在成人非肿瘤性气管狭窄中的应用

目的：探讨金属支架在成人非肿瘤性气管狭窄治疗中的可行性及疗效。方法：7例非肿瘤因素造成成人患者气管狭窄,除1例全喉术后气管瘘口段狭窄较小以外,其余6例气管狭窄长度均在4cm以上;因患者不能或不愿接受常规外科手术治疗,采用记忆性钛合金支架治疗;其中4例使用了无硅胶膜支架,3例使用了硅胶膜支架。结果：支架治疗的7例患者,术后梗阻症状缓解,除1例全喉术后患者外其余6例患者在术后均拔除了气管套管、关闭了气管瘘口,并恢复了正常的呼吸及发声功能;纤维喉镜随访检查显示大多数患者对支架耐受好,局部仅发生轻度炎性反应、肉芽增生,经处理后病情稳定;1例患者术后6个月因局部炎性反应、肉芽增生而再次狭窄,需再次气管切开;另1例患者因局部不适反应明显,于术后10个月拔除支架,随访检查未见再次狭窄。结论：金属支架治疗方法近期效果稳定,操作简便,不良反应少,尤其适合部分不能进行常规外科手术治疗的患者,中、远期疗效需进一步观察。     

A model of canine tracheal stenosis induced by radiofrequency cauterization

Objective

The current methods of management of tracheal stenosis have disadvantages and are controversial, therefore ideal experimental animal models for the further studies are required. The aim of this study was to establish a new model of canine tracheal stenosis by radiofrequency cauterization.

Methods

The tracheal cartilage ring was injured by radiofrequency at the level of the sixth tracheal ring in 12 mongrel dogs. A fibrolaryngoscope was used to guide the procedure. The animals were observed after operation and examined after euthanasia. Endoscopic and histological examinations were undertaken to evaluate the progress of stenosis. The degree of stenosis was calculated using the formula: degree of stenosis = (initial lumen area − final lumen area)/initial lumen area × 100%.

Results

Tracheal stenosis had developed in all dogs by the 21st day post operation. Costal retraction was observed in all dogs after the 18th day post operation. At the end of the study, gross and endoscopic examinations showed that stenosis had been induced to a satisfactory degree and without any complications. The median of the degree of stenosis was 92%, with a range of 84-94%. Histological examination showed that cartilage was damaged and that granulation tissue and collagen fibres had formed.

Conclusions

The model of canine tracheal stenosis induced by radiofrequency cauterization is a relatively simple, reliable, and reproducible animal model. This model may be useful in the development of new methods of treatment for tracheal stenosis.     

Tracheoesophageal fistula with tracheal stenosis resulting from retained esophageal foreign body

Although a foreign body ingestion is common in infants and young children, serious complication such as penetration of the esophagus is a relatively rare event. Delayed diagnosis may result from lack of classical symptoms and history, leading to serious result, even to death. A 2-year-old boy was admitted to the emergency room with dyspnea. He had wheezing and stridor for a 1.5-year and unfortunately treated as a bronchial asthma for a long time. Chest X-ray and cervical CT scan revealed esophageal foreign body. Intraoperative findings showed a plastic material in the esophagus and tracheoesophageal fistula with tracheal stenosis as a complication of the retained foreign body. Therefore, we should keep in mind that foreign body can present atypical symptoms like respiratory symptoms, especially in infant and young children.     

Patterns of cartilage structural protein loss in human tracheal stenosis

OBJECTIVES: The study sought to identify which of the major structural proteins in tracheal cartilage are lost in the inflammatory process, and to determine whether damaged cartilage shows signs of regeneration and whether this is an age-dependent phenomenon. STUDY DESIGN: Immunohistochemical analysis. METHODS: Archival human tracheal and subglottic stenosis segments removed for the treatment of airway compromise were investigated by means of immunohistochemical analysis for differential loss of collagen type I or type II or aggrecan. RESULTS: Specimens were found to have preferentially lost collagen I and aggrecan in areas of severe disruption of the cartilage ring. Collagen II was preserved. In addition, areas of apparent cartilage regeneration were identified based on increased collagen II and aggrecan relative to baseline levels in uninjured sections of the rings. Regenerative capacity was present in most of the specimens investigated and was not age specific. CONCLUSIONS: Collagen I and aggrecan are lost in areas of severe ring compromise, indicating that at least one of these two molecules is responsible for structural integrity. The remaining cartilage has some regenerative capacity, but it is small relative to the degree of cartilage damage. No new collagen I was identified in the cartilage ring, indicating that, although an intense inflammatory reaction occurred, fibroblasts did not deposit new collagen I as seen in other scar tissues.     

气管袖状切除及断端一期吻合手术治疗良性颈段气管狭窄

目的 探讨采用气管袖状切除及断端一期吻合手术治疗良性颈段气管狭窄的疗效及并发症的预防.方法 回顾性分析2009年10月至2012年6月收治的12例因不同病因所致良性颈段气管狭窄并接受手术治疗的病例.术前采用纤维电子喉镜、螺旋CT及三维重建对颈段气管狭窄的位置、范围及局部炎性反应水肿情况进行评估.采用The Myer-Cotton grading系统评价气管狭窄的严重程度.全部病例采用气管袖状切除后断端一期吻合.结果 本组中气管狭窄长度为2.3～4.1 cm.颈段气管狭窄的严重程度:Ⅰ级0例;Ⅱ级3例;Ⅲ级7例;Ⅳ级2例.12例患者术后全部顺利拔管,术后出现暂时性声音嘶哑1例次(8.3％),单侧肺不张合并胸腔积液1例次(8.3％),皮下气肿伴伤口感染1例次(8.3％),轻度吞咽困难3例次(25.0％),气管吻合口炎性肉芽组织增生3例次(25.0％),暂时性音调变低5例次(41.7％).未出现吻合口瘘或断裂等严重并发症.所有病例随访6 ～38个月未出现气管再次狭窄致呼吸困难情况.结论 气管袖状切除并断端一期吻合术手术成功率高,疗效显著,是治疗颈段良性气管狭窄安全可靠的治疗方法,术前应谨慎评估和严格把握适应证.     

喉气管狭窄重建术20年经验

为了提高喉气管狭窄的重建技术。总结２０年来２６１例喉气管狭窄的治疗。８８．８％患者术前都依靠气管切开套管呼吸。主要手术方法：声门重建术；栅栏状喉气管重建术；喉气管切开加自体或人工合成移植物重建术等。结果：２６１例中，９例未愈，５例失访；２４７例（９４．６％）已拔管治愈。１９２例随访１～１８年，４例３年后再狭窄，其中３例再手术治愈。１０例未愈，１８２例（９４．７％）疗效巩固。结论：喉气管狭窄的治疗应根据病情选择手术方法和移植物；栅栏状喉气管重建术具有方法简单，抗感染力强优点；严重喉气管狭窄、闭锁或合并气管大面积缺损以双蒂肌皮瓣、复合肋软骨和人工气管环重建术效果较好；支撑器的应用在喉气管重建中有重要作用。     

Dilatation tracheoscopy for laryngeal and tracheal stenosis in patients with Wegener’s granulomatosis

Wegener’s granulomatosis (WG) frequently involves the subglottis and trachea and may compromise the upper airway. The objective of this study is to evaluate retrospectively the effect of treatment of subglottic stenosis (SGS) and tracheal stenosis (TS) by dilatation tracheoscopy (DT) in patients with WG. We performed a cohort study on all patients who underwent DT between February 2001 and September 2005 in our institution. From this cohort we identified a total of nine WG patients. In all patients, clinical, serological and histopathological data had been prospectively collected by a standardized protocol from the time point of diagnosis. In the nine patients that were identified with SGS or TS due to WG (eight women and one man), a total of 22 DT’s were performed. Two patients needed a tracheostoma (one temporarily). The mean follow-up after the first DT was 25.4 ± 14.1 months. Two patients did not experience a recurrence of SGS or TS. Six patients required a second DT without recurrence of local disease. The remaining patient underwent 8 DT's in a 4-year period. DT can offer a simple and repeatable solution to SGS and TS due to WG. Seven of the nine patients required more than one dilatation and some patients experience a functional restriction. One patient has a definitive tracheostoma.